• Employee Accident Report Form

• 
  
• Today's Date
• Date of Accident*
• Time

  :AMPM
• Employee Name
• Employee Email
• Employee Phone

  --
• Department
• Supervisor Name
• Supervisor Phone

  --
• 
  
• Location of Accident (room, building, facitlity, etc.)
• Description of the accident (as detailed as possible)*
• Was medical assistance required?*
  Yes No

  Was EMS called?
• Other action taken/assistance administered*
• Witness Name and Phone
• Witness Name and Phone
• Employee Signature*
• Supervisor Signature*